Research

JAMA Surgery | Original Investigation

Association Between Preoperative Hemoglobin A1c Levels,

Postoperative Hyperglycemia, and Readmissions
Following Gastrointestinal Surgery
Caroline E. Jones, MD, MSPH; Laura A. Graham, MPH; Melanie S. Morris, MD; Joshua S. Richman, MD, PhD;
Robert H. Hollis, MD; Tyler S. Wahl, MD; Laurel A. Copeland, PhD; Edith A. Burns, MD; Kamal MF Itani, MD;
Mary T. Hawn, MD, MPH

Supplemental content
IMPORTANCE Preoperative hyperglycemia is associated with adverse postoperative
outcomes among patients who undergo surgery. Whether preoperative hemoglobin A1c
(HbA1c) or postoperative glucose levels are more useful in predicting adverse events following
surgery is uncertain in the current literature.

OBJECTIVE To examine the use of preoperative HbA1c and early postoperative glucose levels
for predicting postoperative complications and readmission.

DESIGN, SETTING, AND PARTICIPANTS In this observational cohort study, inpatient

gastrointestinal surgical procedures performed at 117 Veterans Affairs hospitals from 2007 to
2014 were identified, and cases of known infection within 3 days before surgery were
excluded. Preoperative HbA1c levels were examined as a continuous and categorical variable
(<5.7%, 5.7%-6.5%, and >6.5%). A logistic regression modeled postoperative complications
and readmissions with the closest preoperative HbA1c within 90 days and the highest
postoperative glucose levels within 48 hours of undergoing surgery.

MAIN OUTCOMES AND MEASURES Postoperative complications and 30-day unplanned

readmission following discharge.

RESULTS Of 21 541 participants, 1193 (5.5%) were women, and the mean (SD) age was 63.7
(10.6) years. The cohort included 23 094 operations with measurements of preoperative
HbA1c levels and postoperative glucose levels. The complication and 30-day readmission
rates were 27.2% and 14.7%, respectively. In logistic regression models adjusting for HbA1c,
postoperative glucose levels, postoperative insulin use, diabetes, body mass index
(calculated as weight in kilograms divided by height in meters squared), and other patient Author Affiliations: University of
and procedural factors, peak postoperative glucose levels of more than 250 mg/dL were AlabamaBirmingham, Department
associated with increased 30-day readmissions (odds ratio, 1.18; 95% CI, 0.99-1.41; P = .07). of Surgery; Birmingham Veterans
Administration Hospital, Birmingham
By contrast, a preoperative HbA1c of more than 6.5% was associated with decreased 30-day
(Jones, Graham, Morris, Richman,
readmissions (odds ratio, 0.85; 95% CI, 0.74-0.96; P = .01). As preoperative HbA1c increased, Hollis, Wahl); Central Texas Veterans
the frequency of 48-hour postoperative glucose checks increased (4.92, 6.89, and 9.71 for an Health Care System, Temple
HbA1c <5.7%, 5.7%-6.4%, and >6.5%, respectively; P < .001). Patients with a preoperative (Copeland); Clement J. Zablocki
Veterans Affairs Medical Center,
HbA1c of more than 6.5% had lower thresholds for postoperative insulin use. Milwaukee, Wisconsin (Burns);
Veteran Affairs Boston Health Care
CONCLUSIONS AND RELEVANCE Early postoperative hyperglycemia was associated with System and Tufts University School of
Medicine, Department of Surgery,
increased readmission, but elevated preoperative HbA1c was not. A higher preoperative HbA1c
Boston, Massachusetts (Itani);
was associated with increased postoperative glucose level checks and insulin use, suggesting Stanford University, Department of
that heightened postoperative vigilance and a lower threshold to treat hyperglycemia may Surgery; Veteran Affairs Palo Alto
explain this finding. Health Care System, Palo Alto,
California (Hawn).
Corresponding Author: Mary T.
Hawn, MD, MPH, Department of
Surgery, Stanford University,
300 Pasteur Dr, M121 Always Bldg,
JAMA Surg. doi:10.1001/jamasurg.2017.2350 Stanford, CA 94305
Published online July 26, 2017. (mhawn@stanford.edu).

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 Research Original Investigation
P
erioperative hyperglycemia is common among surgi-
cal patients and has been associated with adverse
outcomes.1 Chronic hyperglycemia causes hemoglo-
bin glycation and can be measured by hemoglobin A1c (HbA1c),
which reflects the mean glucose level for the previous 120
days.2 The American Diabetic Association uses HbA1c levels of
5.7% to 6.4% and more than 6.5% for diagnosing prediabetes
and diabetes, respectively.3 Patients with elevated HbA1c ex-
perienced more postoperative infections and longer hospital
stays.4,5 Hemoglobin A1c can also be used to identify patients
who are at an increased risk for developing acute postopera-
tive hyperglycemia,6 which has also been linked to postop-
erative complications, including surgical site infections, an in-
creased length of hospital stay, and mortality.7-14
The current literature lacks consensus on whether preop-
erative HbA1c or postoperative hyperglycemia is more useful
for predicting adverse events following surgery.12,15-17 In ad-
dition, much of the literature pertains to cardiac surgery, which
represents a unique patient population that may not be gen-
eralizable to patients undergoing gastrointestinal surgery who
are at a higher risk for developing postoperative infections. Fi-
nally, to our knowledge, while the relationship between peri-
operative hyperglycemia and postoperative complications has
been examined, the effect of this relationship on readmission
is largely unknown.
We examined the use of preoperative HbA1c and early post-
operative glucose levels for predicting postoperative compli-
cations and readmission. We hypothesized that postopera-
tive glucose level measurements in patients with elevated
preoperative HbA1c are more vigilantly monitored with a lower
threshold of hyperglycemia for insulin treatment. We thereby
assessed postoperative glucose level surveillance and insulin
treatment among patients with different ranges of pre-
operative HbA1c. We hypothesized that elevated early post-
operative glucose levels would have greater use than preop-
erative HbA1c for predicting complications and increased
readmissions.
Methods
We conducted a secondary analysis of the Veteran Affairs Sur-
gical Quality Improvement Program (VASQIP) database to per-
form a retrospective observational study of the relationship
between preoperative HbA1c, perioperative glucose levels, post-
operative complications, and 30-day readmissions. The study
protocol was reviewed and approved by the VA Central insti-
tutional review board with a waiver of informed consent
granted. The Strengthening of Observational Study Designs in
Epidemiology checklist was followed.
Study Population
The study population includes a subset of patients who were
experiencing inpatient digestive surgeries (principal Current
Procedural Terminology codes 40000-49999) at a Veterans
Healthcare Administration hospital between October 1, 2007,
and September 31, 2014, and who were assessed by VASQIP.
Initially, 350 593 unique hospital stays involving a VASQIP-
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Preoperative Hemoglobin A1c, Postoperative Hyperglycemia, and Readmissions
Key Points
Question Are levels of preoperative hemoglobin A1c or early
postoperative glucose more useful at predicting postoperative
complications and readmission following gastrointestinal surgery?
Findings This retrospective observational cohort study of 23 094
operations at 117 Veterans Affairs medical centers found that peak
postoperative glucose levels of less than 250 mg/dL were
significantly associated with increased 30-day readmissions. By
contrast, preoperative hemoglobin A1c of more than 6.5% was
significantly associated with decreased 30-day readmissions.
Meaning Increased glycemic monitoring and the early treatment
of hyperglycemia to maintain peak blood glucose levels of less
than 250 mg/dL during the early postoperative period may
minimize a patients risk of developing complications and being
readmitted after undergoing gastrointestinal surgery.
assessed surgery were identified by VASQIP. Eligible surger-
ies were limited to digestive surgeries only by their principal
Current Procedural Terminology code (40000-49999). Pa-
tients were excluded from the analysis if they had experi-
enced a documented preoperative infection or infectious com-
plication during the 96 hours immediately following their
operation. Patients were also excluded from the analysis if they
were missing a postoperative glucose level assessment or pre-
operative HbA1c assessment. The final analytic sample in-
cluded 23 094 unique hospital stays involving at least 1 VASQIP-
assessed surgical procedure (Figure 1). The unit of analysis for
this study was the index surgical procedure. If a patient had
undergone more than 1 digestive surgery during a hospital-
ization, only the procedural characteristics of the first sur-
gery were included in the analysis.
Data Sources
The covariates of interest included in this analysis were col-
lected from the VASQIP, the VA Decision Support System (DSS),
and the VA Corporate Data Warehouse Inpatient data do-
mains. Preoperative, operative, and postoperative character-
istics were obtained from VASQIP. The VA Surgical Quality Im-
provement Program collects these characteristics via a trained
nurse abstractor, thus ensuring the reliability of the variables
collected.18 Inpatient administrations of insulin in the post-
operative period were identified within the DSS pharmacy data.
Insulin use in the postoperative period was defined as any
administration of insulin during the 48 hours following an
operation.
Variables
The main exposure of interest was the closest preoperative
HbA1c in the 90 days before a hospital admission as assessed
by DSS (DSS laboratory result number, 17) and the highest post-
operative glucose level during the 48 hours following an op-
eration (DSS laboratory result number of 10 or 57). Hemoglo-
bin A1c was collected as a continuous variable and categorized
as normal (<5.7%), prediabetic (5.7%-6.4%), or diabetic (>6.4%).
These categories correspond to a 90-day preoperative mean
glucose level of less than 117, 117 to 137, and more than 137 mg/
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 Preoperative Hemoglobin A1c, Postoperative Hyperglycemia, and Readmissions
Figure 1. Study Flowchart
361 214 Surgeries
10 621 Subsequent surgeries excluded
350 593 Hospital stays
269 216 Excluded
267 368 Nondigestive surgeries
1848 Participants with infectious
complicationsa
89 628 Digestive surgeries
57 299 Excluded (surgeries missing
a postoperative glucose level
assessment)
32 329 Complete in-hospital postoperative
glucose level assessments
9235 Excluded (surgeries missing a
hemoglobin A1c assessment
in the 90 d before surgery)
23 094 Hemoglobin A1c assessment within
90 d preoperative
1553 Surgeries with a preoperative
infection excludeda
21 541 Final sample
a
All preoperative infectious complications were excluded as well as the
infectious complications that occurred in the 96 hours postoperatively.
dL, respectively. The peak glucose level was also collected as
a continuous variable and examined as a 4-category variable
for ease of interpretation (<120, 120-179, 180-250, and >250)
after carefully examining trends between glucose as a con-
tinuous variable and each of the outcomes examined. In ad-
dition to the glucose result, the frequency of glucose level
checks was also calculated as the total number of all com-
pleted glucose results during the 48 hours following an
operation. We limited the postoperative setting to 48 hours
to minimize the effect of postoperative events on our
outcomes.
The covariates of age, sex, body mass index (BMI) (calcu-
lated as weight in kilograms divided by height in meters
squared), American Society of Anesthesiologists (ASA) clas-
sification, preoperative HbA1c, preoperative glucose level, peak
postoperative glucose level, emergency case status, and post-
operative length of stay were selected a priori because they are
significant predictors for and markers of readmission.19 All vari-
ables, with the exception of race/ethnicity and ASA classifica-
tion, were complete. While ASA classification was only miss-
ing for 4 patients (0.02%), race/ethnicity was missing for 3016
patients (14.8%). Race/ethnicity was not a statistically signifi-
cant predictor of any of the outcomes and thus an unlikely con-
founder. Notably, when race/ethnicity was tested we found no
evidence of collinearity between preoperative diabetes, post-
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Original Investigation Research
operative blood glucose, and postoperative insulin use. Fur-
thermore, there was no change in the interpretation of re-
sults when the variables were removed from the models.
The main outcome of interest was postdischarge readmis-
sion or the development of an infection-related postopera-
tive complication as identified by VASQIP. While postopera-
tive infections (a wound infection, pneumonia, urinary tract
infecgtion, or sepsis) are not mutually exclusive, they were
counted only once in the overall postoperative complications
variable. We excluded all patients with a known infection pre-
operatively and for 96 hours postoperatively to minimize the
likelihood that hyperglycemia during the first 48 hours re-
flected an ongoing infection. Inpatient readmissions in the 30
days following a hospital discharge were identified using the
Corporate Data Warehouse Inpatient data domain.
Statistical Analysis
Univariate and bivariate statistics were used to examine the
population and compare patients in terms of diabetes status.
Univariate and bivariate differences in postoperative out-
comes were examined by HbA1c categories, glucose catego-
ries, and insulin use. In unadjusted analyses, 2 tests or Kruskal-
Wallis tests were used to test for differences across the groups.
Smoothed plots were developed to examine changes in event
rates across preoperative HbA1c values. Logistic models ad-
justing for clinically relevant preoperative and operative char-
acteristics were used to calculate the odds of each outcome
across categories of preoperative HbA1c and postoperative glu-
cose. Preoperative HbA1c was added to the adjusted peak 48-
hour glucose levels model to understand the contribution of
peak 48-hour glucose levels independently of preoperative
HbA1c. Peak 48-hour glucose levels were not included in the
preoperative HbA1c model. All analyses were completed using
SAS, version 9.4 (SAS Institute). Smoothed plots were devel-
oped using the R package GGPLOT2.20 Interaction terms were
tested in the final model and included in the final model if sta-
tistically significant at P < .05.
Results
Patient and Procedural Characteristics
Patient and procedural factors stratified by a preoperative di-
agnosis of diabetes by VASQIP are summarized in Table 1. The
mean age for the overall cohort was 63.7 years. Most patients
were men (n = 20 348, 94.5%). Patients with diabetes who were
insulin-dependent had a higher BMI (32.0 vs 30.1; P < .001),
included more patients with an ASA classification of 4 to 5
(19.8% vs 13.3%; P < .001), experienced more postoperative
complications (29.8% vs 26.6%; P < .001), and had more 30-
day readmissions (16.6% vs 14.2%; P < .001). Patients with dia-
betes who were insulin-dependent also had higher preopera-
tive glucose levels (166.1 vs 133.4 mg/dL; P < .001), initial
postoperative glucose levels (190.7 vs 160.0 mg/dL; P < .001),
and peak 48-hour postoperative glucose levels (230.8 vs 182.0
mg/dL; P < .001). The mean HbA1c for the cohort was 6.7%, with
7.0% among patients with diabetes who were noninsulin-
dependent and 8.0% among patients with diabetes who were
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 Research Original Investigation Preoperative Hemoglobin A1c, Postoperative Hyperglycemia, and Readmissions

Table 1. Patient Factors, Procedural Factors, and Outcomes by Diabetes Status

Nondiabetic
All (n = 10 545, NIDDM IDDM
Characteristic (n = 21 541) 49.0%) (n = 5857, 27.2%) (n = 5139, 23.9%) P Value
Patient Factors
Age, mean (SD), y 63.7 (10.6) 62.8 (11.6) 65.1 (9.6) 64.1 (9.4) <.001
Sex, No. (%)
Women 1193 (5.5) 707 (6.7) 293 (5.0) 195 (3.8)
<.001
Men 20 348 (94.5) 9838 (93.3) 5564 (95.0) 4944 (96.2)
BMI, % 30.1 (7.2) 28.7 (6.9) 31.0 (6.9) 32.0 (7.5) <.001
ASA classification,
No. (%)
1-2 2675 (12.4) 1930 (18.3) 492 (8.4) 251 (4.9)
3 16 007 (74.3) 7476 (70.9) 4662 (79.6) 3870 (75.3) <.001
4-5 2855 (13.3) 1139 (10.8) 703 (12.0) 1018 (19.8)
Preoperative HbA1c
Closest within 90 d, 6.7 (1.5) 5.9 (0.7) 7.0 (1.3) 8.0 (1.7) <.001
mean (SD)
<5.7%, No. (%) 4601 (21.4) 3986 (37.8) 416 (7.1) 200 (3.9)
5.7-6.5%, No. (%) 8118 (37.7) 5420 (51.4) 1968 (33.6) 730 (14.2) <.001
>6.5%, No. (%) 8822 (41.0) 1139 (10.8) 3479 (59.4) 4209 (81.9)
Glucose level, mean (SD),
mg/dL
Closest preoperative 133.4 (52.8) 111.7 (30.7) 143.9 (50.1) 166.1 (69.0) <.001
Closest postoperative 160.0 (54.4) 136.3 (39.8) 171.0 (50.1) 190.7 (62.3) <.001
Highest postoperative 182.0 (69.1) 146.4 (48.8) 196.4 (60.8) 230.8 (73.8) <.001
Procedural factors
Emergency case, 2667 (12.4) 1392 (13.2) 627 (10.7) 653 (12.7) <.001
No. (%)
Postoperative LOS, d 6.3 (4.9) 6.3 (4.9) 6.2 (4.8) 6.5 (5.0) <.001
Outcomes
Any postoperative 5731 (26.6) 2657 (25.2) 1540 (26.3) 1531 (29.8) <.001
complication, No. (%) Abbreviations: ASA, American
Infectious complications, Society of Anesthesiologists; BMI,
No. (%) body mass index (calculated as
Wound infection 1230 (5.7) 559 (5.3) 334 (5.7) 339 (6.6) .003 weight in kilograms divided by height
Pneumonia 274 (1.3) 148 (1.4) 64 (1.1) 67 (1.3) .26 in meters squared); HbA1c,
hemoglobin A1c; IDDM,
UTI 448 (2.1) 190 (1.8) 129 (2.2) 123 (2.4) .03
insulin-dependent diabetes mellitus;
Sepsis 412 (1.9) 190 (1.8) 105 (1.8) 113 (2.2) .33 LOS, length of stay; NIDDM,
Postdischarge outcomes, noninsulin dependent diabetes
No. (%) mellitus; UTI, urinary tract infection.
Readmission within 2175 (10.1) 981 (9.3) 586 (10.0) 606 (11.8) <.001 To convert to millimoles per liter,
14 d multiply by 0.0555.
Readmission within 3048 (14.2) 1371 (13.0) 820 (14.0) 853 (16.6) <.001 To convert to the proportion of total
30 d
hemoglobin, multiply by 0.01.

insulin-dependent (P < .001). Of 10 545 patients who did not
receive a preoperative diagnosis of diabetes, the mean HbA1c
was 5.9%, with 3986 patients (37.8%) having 5.7% or less (nor-
mal), 5420 (51.4%) ranging from 5.7% to 6.4% (prediabetic),
and 1139 (10.8%) more than 6.5%, diagnostic of diabetes.
Postoperative Complications by HbA1c and Glucose
Elevated preoperative HbA1c was associated with decreased
postoperative complications even after adjusting for age, sex,
ASA class, wound class, work relative value units, postopera-
tive hospital length of stay, diabetes diagnosis, and insulin use
(Table 2). As compared with patients with normal HbA 1c
(<5.7%), patients with HbA1c more than 6.5% were signifi-
cantly less likely to develop any postoperative complications
(odds ratio [OR], 0.89; 95% CI, 0.80-0.99; P = .03) or to be re-
admitted within 30 days (OR, 0.85; 95% CI, 0.74-0.96; P = .01).
The frequencies of each complication stratified by preopera-
tive HbA1c are summarized in Table 3.
By contrast, elevated peak 48-hour postoperative blood
glucose levels were associated with increased odds for devel-
oping postoperative complications, but these associations were
only marginally significant after adjusting for other patient
characteristics (Table 2). After adjustment, only 30-day read-
missions remained significantly associated with peak 48-
hour postoperative glucose levels (>250 vs <120 mg/dL; OR,
1.20; 95% CI, 1.01-1.42).
The interaction of preoperative HbA1c and postoperative
glucose was of specific interest, but we failed to find a statis-

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 Preoperative Hemoglobin A1c, Postoperative Hyperglycemia, and Readmissions Original Investigation Research

Table 2. Unadjusted and Adjusted ORs of Postoperative Complication by Preoperative Hemoglobin A1c and Postoperative Blood Glucose Levelsa

Preoperative HbA1c %, OR (95% CI) Peak 48-h Postoperative Blood Glucose Level, mg/dL, OR (95% CI)
Normal Prediabetic Diabetic
Outcome (<5.7%) (5.7%-6.4%) (>6.5%) <120 120-180 180-250 >250
Unadjusted
Any postoperative 1 [Reference] 0.93 (0.86-1.02) 0.90 (0.82-0.99) 1 [Reference] 1.28 (1.15-1.42) 1.41 (1.26-1.58) 1.60 (1.41-1.82)
complication
All infectious complications
Wound infection 1 [Reference] 0.89 (0.76-1.05) 0.94 (0.79-1.11) 1 [Reference] 1.32 (1.06-1.62) 1.53 (1.22-1.91) 1.48 (1.15-1.90)
Pneumonia 1 [Reference] 0.94 (0.69-1.29) 0.59 (0.42-0.84) 1 [Reference] 1.67 (1.07-2.61) 1.80 (1.11-2.89) 2.17 (1.27-3.70)
UTI 1 [Reference] 0.95 (0.73-1.25) 0.94 (0.71-1.24) 1 [Reference] 1.59 (1.09-2.31) 2.15 (1.46-3.17) 2.21 (1.44-3.40)
Sepsis 1 [Reference] 0.95 (0.72-1.25) 0.83 (0.62-1.11) 1 [Reference] 1.86 (1.25-2.78) 2.16 (1.42-3.29) 2.80 (1.77-4.40)
Postdischarge outcomes
Readmission within 14 d 1 [Reference] 0.99 (0.87-1.12) 0.92 (0.81-1.06) 1 [Reference] 1.11 (0.95-1.30) 1.28 (1.09-1.52) 1.54 (1.28-1.86)
Readmission within 30 d 1 [Reference] 0.95 (0.85-1.06) 0.86 (0.77-0.97) 1 [Reference] 1.16 (1.01-1.32) 1.28 (1.11-1.48) 1.63 (1.39-1.91)
Adjusted
Any postoperative 1 [Reference] 0.95 (0.87-1.04) 0.89 (0.80-1.00) 1 [Reference] 1.04 (0.93-1.16) 1.03 (0.90-1.17) 1.12 (0.97-1.29)
complication
All infectious complications
Wound infection 1 [Reference] 0.91 (0.77-1.09) 0.95 (0.78-1.17) 1 [Reference] 1.01 (0.82-1.26) 1.04 (0.82-1.33) 0.99 (0.75-1.30)
Pneumonia 1 [Reference] 1.04 (0.75-1.45) 0.77 (0.51-1.17) 1 [Reference] 0.95 (0.60-1.51) 0.81 (0.48-1.36) 0.82 (0.46-1.47)
UTI 1 [Reference] 0.93 (0.70-1.23) 0.98 (0.70-1.35) 1 [Reference] 0.99 (0.67-1.46) 1.07 (0.70-1.62) 1.03 (0.64-1.64)
Sepsis 1 [Reference] 1.04 (0.78-1.39) 1.02 (0.72-1.44) 1 [Reference] 1.09 (0.72-1.66) 1.02 (0.65-1.61) 1.22 (0.74-2.00)
Postdischarge outcomes
Readmission within 14 d 1 [Reference] 1.01 (0.88-1.15) 0.89 (0.76-1.05) 1 [Reference] 0.98 (0.83-1.15) 1.04 (0.86-1.24) 1.19 (0.97-1.46)
Readmission within 30 d 1 [Reference] 0.96 (0.85-1.07) 0.81 (0.71-0.93) 1 [Reference] 0.99 (0.86-1.14) 0.98 (0.84-1.15) 1.18 (0.99-1.41)
a
Abbreviations: HbA1c, hemoglobin A1c; OR, odds ratio; UTI, urinary tract Adjusted for sex, age, body mass index (calculated as weight in kilograms
infection. divided by height in meters squared), American Society of Anesthesiologists
To convert to millimoles per liter, multiply by 0.0555. classification, wound classification, work relative value unit, postoperative
hospital length of stay, preoperative diabetes, and postoperative insulin use.
To convert to the proportion of total hemoglobin, multiply by 0.01.

Table 3. Complications by Preoperative Hemobglobin A1c

No. (%)
Preoperative HbA1c, % Peak 48-h Postoperative Glucose Level, mg/dL
Normal Prediabetic Diabetic
(<5.7) (5.7-6.4) (6.5) P Value <120 120-180 180-250 >250 P Value
Any postoperative complication 1346 (27.3) 2248 (26.1) 2683 (28.1) .01 2084 (26.5) 1614 (28.1) 571 (22.2) 1094 (30.2) <.001
Infectious complications
Wound infection 270 (5.5) 445 (5.2) 594 (6.2) .01 452 (5.7) 381 (6.6) 114 (4.4) 232 (6.4) <.001
Pneumonia 76 (1.5) 125 (1.5) 104 (1.1) .03 114 (1.5) 76 (1.3) 24 (0.9) 49 (1.4) .26
UTI 89 (1.8) 173 (2.0) 220 (2.3) .11 159 (2.0) 145 (2.5) 34 (1.3) 87 (2.4) .003
Sepsis 95 (1.9) 171 (2.0) 199 (2.1) .80 157 (2.0) 121 (2.1) 29 (1.1) 89 (2.5) .003
Postdischarge outcomes
Readmission within 14 d 494 (10.0) 867 (10.1) 1038 (10.9) .13 756 (9.6) 617 (10.7) 227 (8.8) 447 (12.3) <.001
Readmission within 30 d 716 (14.5) 1222 (14.2) 1453 (15.2) .13 1083 (13.8) 842 (14.6) 316 (12.3) 633 (17.5) <.001

Abbreviations: HbA1c, hemoglobin A1c; UTI, urinary tract infection.

tically significant interaction between the 2 terms in the ad- 6.5% (P < .001). The frequency of hyperglycemia surveil-
justed model, and it was therefore not included in the final lance by means of glucose level checks increased as the pre-
model. operative HbA1c increased from 3% to 10% (Figure 2A).

Postoperative Glucose Level Surveillance Postoperative Hyperglycemia Treatment

The mean total glucose level was 4.92 for patients with an HbA1c Patients with preoperative HbA1c more than 6.5% have lower
of less than 5.7%, 6.89 for patients with an HbA1c ranging from thresholds for insulin use per postoperative glucose until their
5.7% to 6.4%, and 9.71 for patients with an HbA1c of more than glucose level reaches 240 mg/dL, in which insulin use equal-

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 Research Original Investigation
Figure 2. Postoperative Glucose Level Surveillance and Hyperglycemic Treatment
A Mean No. of postoperative insulin checks by closest
preoperative HbA1c
14
Postoperative Insulin Checks, Mean No.
12
10
8
6
4
0 0
3 4 5 6
Closest Preoperative 90-d HbA1c
A, Mean number of postoperative insulin checks by closest preoperative
hemoglobin AIc (HbA1c). Error bar represents mean 95% CI. B, Proportion of
izes across all preoperative HbA1c categories (Figure 2B). The
closest preoperative HbA1c and glucose levels, as well as the
highest 48-hour glucose levels, were the strongest predictors
of receiving insulin in the 48 hours following surgery. Over-
all, patients with an HbA1c ranging from 5.7% to 6.4% were not
more likely to receive insulin compared with patients with an
HbA1c of less than 5.7%. However, patients with an HbA1c of
more than 6.5% were 1 to 3 times more likely to receive insu-
lin when their postoperative glucose values were less than 250
mg/dL. Specifically, 530 patients (11.5%) with an HbA1c of 5.7%
or less received insulin compared with 1422 (17.5%) with an
HbA1c ranging from 5.7% to 6.4% and 3895 (44.2%) with an
HbA1c of more than 6.4 (P < .01). Once the postoperative glu-
cose level reaches 250 mg/dL, all patients have an equal op-
portunity to receive insulin regardless of postoperative glu-
cose levels. Other factors associated with insulin use are age,
sex, BMI, ASA classification, preoperative diabetes, preopera-
tive sepsis, and hypertensive medications.
Discussion
Patients with insulin-dependent diabetes have higher post-
operative complication rates compared with patients with non-
insulin-dependent diabetes and those without diabetes.4,5
They also have higher 14- and 30-day readmission rates. Even
after adjusting for diabetes, preoperative HbA1c, insulin use,
and BMI, patients with peak 48-hour postoperative blood glu-
cose levels of more than 250 mg/dL are 20% more likely to be
readmitted within 30 days. Contrary to this, patients with a
preoperative HbA1c of more than 6.5% are 17% less likely to be
readmitted within 30 days. We hypothesized that because
HbA1c is known preoperatively, hyperglycemia in these pa-
tients is more vigilantly monitored and treated with insulin.
Our findings indicated that the frequency of glucose level
checks increased with increasing HbA1c until HbA1c equals 10%.
E6 JAMA Surgery Published online July 26, 2017 (Reprinted)
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Preoperative Hemoglobin A1c, Postoperative Hyperglycemia, and Readmissions
B Proportion of patients recieving postoperative insulin by peak
postoperative glucose
80
HbA1c
<5.7%
60 5.7%-6.5%
>6.5%
Received Insulin, %
40
20
7 8 9 10 11 >12 50 100 150 200 250 300 350 400 450 500
Highest Postoperative Glucose, 48 h
patients receiving postoperative insulin by peak postoperative glucose level.
The gray shaded area represents glucose levels less than 5.7%
In addition, the threshold to treat hyperglycemia with insulin
was lower for patients with an HbA1c of more than 6.5%.
The association between postoperative hyperglycemia and
infectious complications is consistent with prior findings.8,10
We believe that postoperative hyperglycemia reflects an acute
inflammatory phase and the hosts response that may lead to
increased postoperative complications. Kotagel et al21 de-
scribed a dose-dependent association between hyperglyce-
mia and adverse events among patients without diabetes. The
authors attributed this finding to several theories, including
that patients with diabetes may be more likely to be tested and
treated for hyperglycemia. Our findings suggest this theory
holds true, and our study expands on this work by looking at
readmissions.
The current literature lacks consensus regarding the as-
sociation between HbA1c and postoperative complications that
lead to readmission,12,22 and the finding of elevated HbA1c as
protective of postoperative complications and readmissions
is novel. It has been proposed that HbA1c is the most signifi-
cant predictor of postoperative complications, partially be-
cause preoperative hyperglycemia corresponds to postopera-
tive hyperglycemia and the ability to control it.17 As opposed
to creating separate models for preoperative and postopera-
tive hyperglycemia, we created one model that accounted for
HbA1c, postoperative hyperglycemia, diabetes status, and in-
sulin use and found that HbA1c was not a significant predictor
of complications and was protective of 30-day readmission.
We tested whether elevated HbA1c is protective of post-
operative complications and thereby readmissions because of
the increased monitoring and treatment of hyperglycemia in
these patients. Only 59% of hospitalized patients undergo glu-
cose monitoring and, of these that are found to be hypergly-
cemic, only 54% are treated with insulin.23 Because the risk
of postoperative complications corresponds to the degree of
hyperglycemia experienced, many have advocated for in-
creased glycemic monitoring and consideration for early
jamasurgery.com
2017 American Medical Association. All rights reserved.
 Preoperative Hemoglobin A1c, Postoperative Hyperglycemia, and Readmissions Original Investigation Research

management.24 However, it has been demonstrated that pa-
tients without diabetes are less likely to receive insulin for
hyperglycemia.25 As patients with elevated HbA1c are consid-
ered to have poorly controlled diabetes, we observed that their
postoperative course is marked by vigilant glycemic monitor-
ing and intervention that may explain the observation of im-
proved outcomes compared with patients with normal HbA1c.
While many advocate for deferring elective surgery in pa-
tients with elevated HbA1c until it is optimized,17 our results
suggest that proceeding may be acceptable as long as there is
vigilant postoperative glucose level monitoring and treat-
ment.
Strengths and Limitations
Our study was limited to patients undergoing gastrointesti-
nal surgery, among whom there are studies on the relation-
ship of diabetes and hyperglycemia on postoperative out-
comes. A strength of this study is the use of all glucose
measurements and treatment in a national cohort of patients
undergoing surgery to evaluate the association of periopera-
tive glucose on complications and readmissions. However, it
also has its limitations. We chose to categorize HbA1c based on
the American Diabetes Association cutoffs for normal (<5.7%),
prediabetes (5.7 6.4%), and diabetes (>6.5%). This study does
not delineate the outcomes for elevated HbA1c of more than
7%, more than 8%, or even more than 10%, in which the power
is lacking. In addition, because we excluded patients who died
in the hospital to examine readmissions, patients with the most
severe complications resulting in in-hospital death were ex-
cluded from this study. However, since we hypothesized that
postoperative hyperglycemia was associated with worse out-
comes, this limitation would result in bias toward the null.
While all patients underwent a procedure in the general sur-
gery specialty, they did not undergo the same procedure. Be-
cause we did not compare the specific type of surgery and pa-
tient perioperative glucose or HbA1c, it is possible that the
results were affected. In addition, there are several potential
confounders, including laparoscopic vs open procedure, in-
dications for surgery, and antibiotic use, which were not ad-
dressed and could limit the study. We also excluded patients
without preoperative HbA1c within 90 days of undergoing sur-
gery or a postoperative glucose level assessment, which may
have introduced selection bias (eTable 1 in the Supplement).
Finally, because our data source is the VA, our patient popu-
lation is predominantly male and as a retrospective study, we
cannot assess causation.
Conclusions
In summary, early postoperative glucose increases the risk of
30-day readmission, whereas elevated preoperative HbA1c is
associated with decreased readmission potentially because of
more intensive monitoring and intervention of postoperative
hyperglycemia. These findings advocate for increased glyce-
mic monitoring in the early postoperative phase and early treat-
ment of hyperglycemia to maintain peak blood glucose levels
of less than 250 mg/dL to minimize the risk for complications
because of hyperglycemia. Further study is warranted to ad-
dress causation.

ARTICLE INFORMATION
Accepted for Publication: April 16, 2017.
Published Online: July 26, 2017.
doi:10.1001/jamasurg.2017.2350
Author Contributions: Ms Graham had full access
to all the data in the study and takes responsibility
for the integrity of the data ant the accuracy of the
data analysis.
Concept and design: Jones, Morris, Wahl, Burns,
Itani, Hawn.
Acquisition, analysis, or interpretation of data: All
authors.
Drafting of the manuscript: Jones, Graham.
Critical revision of the manuscript for important
intellectual content: Graham, Morris, Richman,
Hollis, Wahl, Copeland, Burns, Itani, Hawn.
Statistical analysis: Jones, Graham, Richman, Wahl.
Obtained funding: Graham, Hawn.
Administrative, technical, or material support:
Graham, Burns, Itani.
Supervision: Morris, Richman, Burns, Itani, Hawn.
Other - model development: Copeland.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported by
grant IIR: 12-358 from the Veterans Healthcare
Administration Health Services Research &
Development.
Role of the Funder/Support: This research was
supported by the Veterans Health Administration,
which had no role in the design and conduct of the
study; collection, management, analysis, and
interpretation of the data; preparation, review, or
approval of the manuscript; and decision to submit
the manuscript for publication.
Disclaimer: The views are those of the authors and
do not necessarily reflect the views of the
Department of Veterans Affairs.
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